We are in the midst of a so-called “ear infection” epidemic, which has plagued my practice since starting my job in New York City just over one year ago. While otitis media and otitis externa are in no short supply, I am inundated with patients who clearly have other pathology but are prescribed endless rounds of oral antibiotics and otic drops to no effect. This I believe to be a failure of medical education system as it relates to the ear, and an inability of various front-line practitioners (some otolaryngologists included!) to consider other causes.

Based on empiric observations after listening to thousands of patients, there is a 100% chance of getting a prescription for oral antibiotics or ear drops if you present with an ear complaint to an urgent care, ER, pediatrician, or primary care doctor. Pain, pressure, hearing loss, dizziness, tinnitus, crackling, and popping can only be an infection and the cure-all can only be an antibiotic. I admit that my perspective is likely skewed as an ear specialist — only cases that have not been solved by conventional means make it to my office. With that said, obvious practice patterns are emerging. A good friend of mine recently reported some fluttering and irritation in his ear after a haircut, and went to urgent care to have it evaluated. He was promptly prescribed antibiotic pills and drops and sent home. Before he took them, he asked me to check his ear. His otoscopic exam with conventional tools was completely normal except for a loose hair lying on his ear drum. I removed the hair, and his symptoms resolved immediately. While I do not expect other practitioners to manipulate the ear or attempt procedures they are uncomfortable performing, it is disappointing to see so many unnecessary prescriptions, poor antibiotic stewardship, and flagrant misdiagnosis in this tiny, misunderstood area of the body. Our front-line clinicians are incredibly important and know much more about various conditions outside of the head and neck than I do, but a significant proportion of primary care complaints center around the head and neck and specifically the ear. 

Before you prescribe antibiotics for yet another ear infection, please consider the following differential: 

• Cerumen (wax) impaction: Cerumen is yellow-brown and can be malodorous. It is not, however, of thin consistency and does not leak from the ear. It does not crust on the ear. Patients will often tell you that they put a Q-tip or towel in their ears and removed smelly material. Another frequent story is that someone got out of the shower or pool and their ear felt immediately clogged. Treatment for this is wax disimpaction. 
• Eustachian Tube Dysfunction: This is often a sensation of having clogged ears and subjective, but not objective hearing loss. There may be popping and significant pressure. It is often associated with recent upper respiratory tract infections (URI) and barometric challenges such as flights, elevators, and diving. Symptoms can be cleared temporarily with a Valsalva maneuver, blowing the nose with pinched nostrils, or yawning. It can often occur after an URI or in allergy season. Treatment is often with a few days of decongestants, medicated nasal sprays, allergy treatment, or in severe cases, a short taper of oral steroids. 
• TMJ: The temporomandibular joint (TMJ) is where the mandibular condyle articulates with the rest of the skull and this is just anterior to the ear. It is very common and is often associated with dental issues, jaw clenching, tooth grinding, clicking, and ear pressure. The ear exam should be normal. Treatment consists of warm compresses, NSAIDs, soft foods, and if refractory, referral to a specialized dentist for a possible oral appliance or other implements.  
• Middle ear effusion: This is common after a URI and during allergy season. While otitis media is technically a purulent effusion, most effusions are serous and have yellowish or straw-colored transparent hues. If you look closely, you can often see an air-fluid level or even bubbles. In the setting of a recent URI, this is less concerning, but anyone with a unilateral middle ear effusion needs a scope exam to rule out nasopharyngeal mass. A clear effusion and dripping of thin, clear liquid from one side of the nose is pathognomonic for cerebrospinal fluid leak. 
• Eczematous skin: People with itchy ears, particularly when bilateral, may have reddish ear canal skin and often have flaky wax. They may get a superimposed otitis externa but often do not. Mineral oil and topic steroid drops are often highly effective. 
• Sudden sensorineural hearing loss: The ear exam should be completely normal. If you have a tuning fork, the Weber test (where you put it on the midline forehead, glabella, or maxillary incisors) may lateralize to the better ear (if the loss is significant). If in doubt, prescribe an oral steroid taper and have them see an otolaryngologist ASAP. If confirmed, an MRI of the internal auditory canals to rule out vestibular schwannoma/acoustic neuroma is recommended. 

Otic drops are only effective if you are treating the ear canal skin or if you are targeting the middle ear and there is a perforation in the ear drum. If the ear drum is intact and you are targeting the middle ear, ear drops are completely ineffective. If you are targeting the middle ear and mastoid in the setting of an intact ear drum or if the otitis externa is particularly severe, oral antibiotics may be necessary. 

Alarm symptoms requiring prompt referral to an ER for imaging and evaluation by a specialist in the setting of an ear complaint include facial paralysis, new onset headache or neck stiffness, soaking the pillow in liquid while sleeping, or significant swelling behind the ear/proptosis of the ear. Any new focal neurologic symptoms in the setting of an ear complaint should be treated as an emergency.  

Zachary Schwam, MD is a neurotologist, or specialist in the medical and surgical management of hearing loss and lateral skull base pathology, in the Mount Sinai Health System in New York City. He is the editor of the Otolaryngology Surgical Video Series on Youtube.

Illustration by Jennifer Bogartz